TASMANIAN INFECTION PREVENTION AND CONTROL UNIT Bloodstream Infections Surveillance Module for rural hospitals and non-acute settings. Version 1 Department of Health and Human Services Bloodstream infection - surveillance module for rural hospitals and non-acute settings. Tasmanian Infection Prevention and Control Unit (TIPCU) Department of Health and Human Services, Tasmania Published 2013 Copyright—Department of Health and Human Services Editors • Anne Wells, TIPCU • Fiona Wilson, TIPCU Suggested citation: Wells A., Wilson F. (2013). Bloodstream infection – surveillance module for rural hospitals and non- acute settings. Hobart: Department of Health and Human Services. TASMANIAN INFECTION PREVENTION AND CONTROL UNIT Population Health Department of Health and Human Services GPO Box 125 Hobart 7001 Ph: 6222 7779 Fax: 6233 0553 www.dhhs.tas.gov.au/tipcu 1 Contents Blood stream infection surveillance ........................................................................................................ 3 Background ......................................................................................................................................... 3 Aims .................................................................................................................................................... 3 Inclusion criteria.................................................................................................................................. 3 Exclusion criteria................................................................................................................................. 3 Definitions ........................................................................................................................................... 3 Process for surveillance ...................................................................................................................... 4 BSI investigation flowchart .................................................................................................................. 8 Reporting ............................................................................................................................................ 8 Blood stream infection event sheet .................................................................................................... 9 Blood stream infection investigation guide ....................................................................................... 10 Blood stream infection investigation guide (continued) ................................................................... 11 Fact sheet - intravascular catheter associated BSI ............................................................................ 12 Further information and resources .................................................................................................. 12 References......................................................................................................................................... 13 2 Blood stream infection surveillance This document provides guidance on how to use the TIPCU Bloodstream Infection (BSI) Surveillance module. Accompanying tools include; • BSI investigation flowchart • BSI event sheet • BSI investigation guide • Fact sheet – intravascular catheter associated BSI Background Blood stream infections occur when bacteria enter the bloodstream from either a primary focus of infection in an organ, a wound or via an indwelling or implanted device. Health care associated (HCA) BSIs can occur as complications following medical and surgical procedures or the insertion of an intravascular or indwelling device and a patient may acquire a HCA BSI as a result of treatment in hospitals or as an outpatient. HCA BSI’s are associated with increased morbidity and mortality and many are potentially preventable. Aims • To monitor and measure the incidence of blood stream infections within rural hospitals and non-acute healthcare settings • Assessment of all laboratory detected blood stream infections to determine if the cause may be related to healthcare. Inclusion criteria • Laboratory detection of a recognised pathogen in a blood culture specimen. • The first positive blood culture per patient is counted. Exclusion criteria • Organisms identified as contaminants. • Subsequent positive blood culture/s with the same organism isolated within 14 days. Definitions Recognised Pathogen may include: Staphylococcus aureus Streptococcus pneumoniae, Escherichia coli, Klebsiella, Proteus, Salmonella species, Candida albicans. Potential contaminant organisms may include: coryneforms (Corynebacterium spp., etc.), coagulase-negative staphylococci, micrococci, Propionibacterium, Bacillus, alpha haemolytic streptococci, environmental Gram-negative bacilli, non-pathogenic Neisseria. 3 Process for surveillance The person chosen to undertake BSI Surveillance should be familiar with the BSI Surveillance Definition. When a positive blood culture is reported to the facility, complete a BSI Event Sheet to assess the circumstances surrounding this event. The BSI flowchart summarises this process. All healthcare associated BSIs warrant further investigation to establish the cause where possible and to identify infection prevention and control measures that may prevent further HCA BSI’s. Refer to the BSI Investigation Guide to assist. There are three basic steps to identifying a healthcare associated bloodstream infection (HCA BSI) 1. Identify if the positive blood culture is a bloodstream infection or is a contaminant. 2. If it is a bloodstream infection, where was it acquired? 3. If it was acquired as a result of healthcare, define the source of the infection. The definition used for bloodstream infection surveillance is modified from The Health Care Associated Infection Advisory Committee, Australian Council for Safety and Quality in Health Care (2004), and the CDC/NHSN Surveillance HAI Criteria. 4 Step 1 - Is the positive blood culture a bloodstream infection or a contaminant? A bloodstream infection must meet the conditions of Criterion 1 OR Criterion 2: Criterion 1- recognised pathogens: • Isolation of one or more recognised bacterial or fungal pathogens from one or more blood cultures Criterion 2 - potential contaminants: • The patient has at least one of the following signs and symptoms within 24 hours of a positive blood culture being collected: • Fever (>38oC); • Chills or rigors; or • Hypotension • For patients ≤1 year of age the signs and symptoms included • Fever (>38oC Core) • Hypothermia (<36oC Core) • Apnoea or bradycardia AND at least one of the following: a. There is isolation of the same potential contaminant from two (2) or more blood cultures drawn on separate occasions within a 48 hour period (isolates identified by suitable microbiological techniques) b. There is isolation of a potential contaminant from a single blood culture drawn from a patient with an intravascular line (within 48 hours of the episode) and appropriate antimicrobial therapy against that isolate is commenced. Items of note: If you are unclear if the blood culture result represents a recognised pathogen or contaminant contact the microbiology laboratory. A bloodstream infection due to the same organism(s) that recurs within 14 days of the original event is considered to be the same infection and is not counted as a new episode. When mixed isolates are obtained with one being an accepted pathogen, the potential contaminant organism is to be disregarded. A potential contaminant in a patient with an IVD who has been an inpatient for less than 48 hours could be a healthcare associated BSI. Discuss the patient’s diagnosis with the treating medical team to determine if the BSI is related to the IVD. 5 Step 2 - Where was the bloodstream infection acquired? The bloodstream infection place of acquisition is categorised as either healthcare associated or community associated as follows: Healthcare associated event (HCA BSI) • Events that occur >48 hours after admission and was not incubating on admission OR occurs within 48 hours of discharge. OR • Events that occur <48 hours after admission and meet at least one of the following key clinical criteria: o Is a complication of the presence of an indwelling medical device (e.g. IV catheter, urinary catheter); o Occurs within thirty days of a surgical procedure, where the bloodstream infection is related to the surgical site infection; o An invasive instrumentation or incision related to the bloodstream infection was performed within 48 hours before onset of the infection. If the time interval was longer than 48 hours, there must be compelling evidence that the infection was related to the invasive device or procedure; or o Associated with neutropenia (<1x109/L) contributed to by cytotoxic therapy. Community-associated • The BSI is not healthcare associated and manifests <48 hours after admission unless an organism with a long incubation period (e.g., Salmonella Typhi) is isolated. Items of note: A potential contaminant in a patient with an IVD who has been an inpatient for less than 48 hours could be a healthcare associated BSI. Discuss the patient’s diagnosis with the treating medical team to determine if the BSI is related to the IVD. 6 Step 3 - What is the source of infection of the HCA BSI? Classify each healthcare associated BSI by the site or the focus of principal site of the infection. Unknown focus • A specific site cannot be identified; includes disseminated infections. Indwelling medical device • Classify as either